ORIGINAL ARTICLE
FIXATION OF ADULT EXRTA –ARTICULAR DISTAL THIRD DIAPHYSEAL
FRACTURE OF HUMERUS-A PROSPECTIVE STUDY
Ahmed Parvez, Singh Amit, Gupta Alok, Singh Prashant Pratap, Kumar Dinesh, Ameer Faisal, Sharma
Gajendra.
1.
2.
3.
4.
5.
6.
7.
Professor, Department of Orthopaedics, L.L.R.M. Medical College, Meerut, Uttarpradesh.
Junior Resident, Department of Orthopaedics, L.L.R.M.Medical College, Meerut, Uttarpradesh.
Junior Resident, Department of Orthopaedics, L.L.R.M.Medical College, Meerut, Uttarpradesh.
Junior Resident, Department of Orthopaedics, L.L.R.M.Medical College, Meerut, Uttarpradesh.
Assistant Professor, Department of Orthopaedics, L.L.R.M.Medical College, Meerut, Uttarpradesh.
Assistant Professor, Department of Plastic Surgery, L.L.R.M.Medical College, Meerut, Uttarpradesh.
Junior Resident, Department of Orthopaedics, L.L.R.M.Medical College, Meerut,, Uttarpradesh.
CORRESPONDING AUTHOR:
Dr. Alok Kumar,
Junior Resident,
Dept. of Orthopaedics,
L.L.R.M. Medical College,
Meerut, Uttarpradesh, India.
E-mail: drahmedparvez@yahoo.com
ABSTRACT: Distal humerus fracture in adult is very difficult to treat. It is very difficult to achieve
alignment, anatomical reduction, rigid fixation, immediate mobilization and fracture union in such
patient MATERIAL AND METHOD-We operate 41 patient of close extra articular fracture of distal
third of humerus, using posterior approach. 10 cases were fixed with single locking plate,6 cases by
single distal multiple hole plate,12 cases by two reconstruction plate,6 cases by simple T plate,7cases
by oblique metaphyseal locking plate. RESULT- Double plating with reconstruction plates provide a
more rigid fixation than a single-locked plate. CONCLUSION- Fixation of extra articular distal
humerus, diaphyseal fracture in adult are better with double plating than single plating, which
provide more rigid fixation with early mobilization and higher mayo elbow score.
INTRODUCTION: Fractures of distal humerus are rare injuries in adults (1). Distal humeral
fractures make it difficult to use upper limb for activities of daily living such as eating, wearing
clothes, maintaining body hygiene etc. To use elbow effectively, stable reduction and fixation of
these fractures is necessary. Fractures of the distal humerus remain a challenging problem despite
advances in technique and implants. Joint function often is compromised because of stiffness, pain,
and weakness. Rarely is a “normal” elbow the outcome after these fractures, but outcomes have
been improved with advances in implant technology, surgical approaches, and rehabilitation
protocols.
These fractures are difficult to manage because of poor bone quality in distal humerus. The
appropriate treatment of extra-articular distal humerus fractures is controversial. Most distal
humeral fractures in adults must be treated operatively, in contrast to fractures of the proximal
humerus or humeral shaft. Nonoperative treatment with the “bag of bones” technique may be
reasonable in an elderly patient with significant medical comorbidities. When operative fixation is
indicated for humeral shaft fractures, plate osteosynthesis is the gold standard to which other
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ORIGINAL ARTICLE
methods must be compared5. In distal humeral shaft fractures especially fractures at metaphyseal
junction, this becomes problematic because plates of adequate length can impinge on the olecranon
fossa.
We conducted this study to evaluate the clinical and functional outcomes in patients treated
by different internal fixation methods for extra-articular fractures of distal third of humerus and to
know the relationship between functional outcome and time(after surgery) in patients of our
institution.
MATERIALS AND METHODS: Between July 2008 and December 2012, 41 patients with close extraarticular fracture of distal third of humerus, operated in our institution were included in the study.
The study was a prospective study carried out on the patients with fracture distal third humerus,
attending the outdoor and the emergency services of the Department of Orthopedics in our
institution. The inclusion criteria were; the patients with eighteen years and above age group
presented with fracture distal third humerus, patients with mature skeleton, patients who did not
have other associated bony pathology in ipsilateral limb and the patients who gave their consent to
undergo the procedure. The exclusion criteria were patients with fracture distal third humerus with
compound injury or intraarticular involvement. Pathological fracture with infective or metabolic
bone diseases etiology. Patient with co-morbid condition which preventing surgical intervention or
making patients non- compliant for post operative physiotherapy and follow up, patients with local
tissue condition making the surgery inadvisable. All the patients were subjected to clinical
examination. Radiographic evaluation of the affected side was done at the time of allotment of study
group with the anterior-posterior and lateral views. The radiographs were assessed in terms of
involvement of medial and lateral column and intra articular extension. All patients were
administered general anesthesia. Our standard practice was to give preoperative prophylactic
intravenous antibiotic and usage of tourniquet and unipolar/bipolar diathermy for homeostasis.
They were surgically treated by posterior approach with or without olecranon osteotomy with
exploration of nerves.
Forty one cases (29 dominant hand cases, 19 nondominant hand cases) of fracture were
performed by a senior consultant between July 2008 and December 2012. Of the patients operated,
twelve patients were fixed with two reconstruction locking plates, ten with single locking plate, seven
patients with oblique metaphyseal locking plate, six patients with single distal multiple hole plate and
six patients with simple T plate. In Intra-operative period, alignment of both column and rotation of
distal part was manually checked. If there was any gap that was filled by autologous cortico-cancellus
bone graft taken from iliac crest.
In post operative period, standard rehabilitation program started at 3rd post operative day
with passive movement of elbow and shoulder. Physiotherapy with flexion-extension, supinationpronation movements at elbow joint and range of motion exercises at shoulder joint done.
Patient related outcomes and clinical evaluations were made by an independent observer.
Data obtained from personal interviews and clinical examination was recorded systematically in a
Performa. The Mayo elbow score was used to rate elbow function and to determine satisfaction level
of each patient. They are intended to provide a score of 0 to 100, where a higher score implies a
better outcome. Score is completed by clinicians. The arms were assessed clinically in which the
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main variables examined were pain relief, instability, range of motion and functional improvement.
Radiological assessment was by antero-posterior and lateral views of the operated arm.
RESULT: A total of 41 patients involved were included in the study between July 2008 and December
2012. The primary pathology caused by trauma, either from fall from height or road-traffic accident.
Of the 41 arms that were recruited, 61% or 25 were male and 39% or 16 arms were female. The
mean age of patients at the time of surgery was 48 years (range 18-82 years). The follow up period
vary between 12 months to 4 years, with mean follow up was 1 year 6 months. Among the group
operated by two reconstruction locking plates (12 case), stability was good. Initially at 2 month, Mayo
elbow performance scores were low due to impingement of soft tissue, but it improved significantly
with physiotherapy and final results were good to excellent. The mean Mayo elbow performance
score at pre-op and post-op 2 month, 6month and 12 month was 18.33, 77.50, 83.75 and 89.17
respectively.
In the group operated by single locking plate, out of 10 cases 4 cases went into failure with
loss of fixation and impingement at olecranon fossa occurred. The mean Mayo elbow performance
score at pre-op and post-op 2 month, 6month and 12 month was 10.0, 64.00, 68.50 and 70.00
respectively.
In the group operated using oblique metaphyseal locking plate (7 cases), there was no failure
but stability of medial pillar was less and Mayo elbow performance scores were comparatively low.
The mean Mayo elbow performance score at pre-op and post-op 2 month, 6month and 12 month
was 14.29, 70.71, 75.71 and 77.14 respectively.
Fixation and Mayo elbow performance scores were very good in the group operated by
single distal multiple hole plate but it was very difficult to use this plate in the patients having more
distally located metaphyseal fracture. The mean Mayo elbow performance score at pre-op and postop 2 month, 6month and 12 month was 18.33, 85.00, 89.17 and 90.83 respectively.
Out of 6 patients, 3 patients went into failure among the group operated using simple T plate.
The mean Mayo elbow performance score at pre-op and post-op 2 month, 6month and 12 month
was 9.17, 58.33, 59.17 and 60.83 respectively.
In this prospective study we have preoperative Mayo scores to compare with the final Mayo
scores of same group and among different operative groups. All finding were statistically tested and
significant.(see table 1 and 2)
Per operative complication was noted in four cases. This was deficient medial and lateral
column (had to be built up with bone graft).In post operative period two case were infected, which
were treated by debridement and antibiotic treatment. In fallow up period seven case were failed
which were revised either by two reconstruction plates or by single distal multiple hole plates with
bone graft.
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ORIGINAL ARTICLE
Pair
1
Pair
2
Pair
3
Pair
4
Pair
1
Pair
2
Pair
3
Pair
4
TABLE – 1: Comparison of Mayo Scores at 2 Months (Unpaired t-test)
Pair
Mean N Standard
Standard error P
value
deviation
of mean
significance
Reconstruction locking 77.50 12 5.44
1.57
0.0356
plate
statistically
significant
Single locking plate
64.00 10 19.97
6.32
Reconstruction locking
plate
oblique
metaphyseal
locking plate
Reconstruction locking
plate
distal multiple hole plate
Reconstruction
plate
Simple T-plate
77.50 12 5.44
1.57
70.71 7
6,73
2.54
77.50 12 5.44
1.57
85.00 6
4.47
1.83
locking 77.50 12 5.44
1.57
58.33 6
9.97
24.43
TABLE – 2: Comparison of Mayo Scores at 12 Months (Unpaired t-test)
Pair
Mean N Standard
Standard error of
deviation
mean
Reconstruction
locking 89.17 12 4.17
1.20
plate
Single locking plate
70
10 22.97
7.26
Reconstruction
locking
plate
oblique
metaphyseal
locking plate
Reconstruction
locking
plate
distal multiple hole plate
Reconstruction
plate
Simple T-plate
89.17 12 4.17
1.20
77.14 7
6.36
2.40
89.17 12 4.17
1.20
90.83 6
3.76
1.54
locking 89.17 12 4.17
1.20
60.83 6
10.99
26.91
/
0.0276
statistically
significant
0.0102
statistically
significant
0.0169
statistically
significant
P
value
significance
0.0099
significant
/
0.0001
significant
0.4226
significant
0.0021
significant
DISCUSSION: Plate osteosynthesis remains the “gold standard” of fixation for humeral shaft
fractures. Plating can be used for fractures with proximal and distal extension and for open
fractures. It provides enough stability to allow early upper extremity weight bearing in polytrauma
patients and produces minimal shoulder or elbow morbidity. Numerous reports in the literature
cite high union rates, low complication rates, and rapid return to function after plate fixation of
humeral shaft fractures. A good technique requires careful preoperative planning, adequate
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ORIGINAL ARTICLE
exposure of the joint and fracture, biomechanically sound internal fixation, and protection of
neurovascular structures. Flexibility on the part of the surgeon and the availability of a wide range
of plates and screws are necessary.
A variety of approaches have been described for reduction and fixation of distal humeral
fractures. Most commonly, a posterior approach with an olecranon osteotomy has been used, but
concerns about healing and symptomatic implants have led to more frequent use of a tricepsreflecting (Bryan-Morrey) or triceps-reflecting anconeus pedicle approach, as advocated by Bryan
and Morrey and O'Driscoll, or a triceps-splitting approach, as advocated by McKee et al. (2). The
best fracture exposure is provided by an olecranon osteotomy approach. The biomechanically
soundest technique appears to be a chevron type osteotomy through the non-articular portion of
the olecranon, predrilled and fixed with inter-fragmentary screw fixation augmented by a tension
band wire. As more familiarity is gained with fracture patterns and reduction techniques, a tricepsreflecting or triceps-splitting approach may be selected to reduce complications. With all posterior
approaches, the ulnar nerve must be carefully dissected without excessive stripping and usually is
transposed anterior to the medial epicondyle at the end of the procedure.
The standard plating technique calls for plates to be placed at orthogonal angles (90-90
plating). Studies by Self et al. and Schemitsch et al. showed that direct medial and lateral plating is
biomechanically sound(3,4) .Newer plates that are pre-contoured or 3.5-mm compression plates
are preferable to one-third tubular and 3.5-mm reconstruction plates because of fatigue failure in
the latter group in fractures with metaphyseal comminution. For low-type fractures, additional
mini fragment plates may provide added fixation .Comminuted fractures may require a bridge
plating technique. Anatomical reduction of each fracture fragment is unnecessary. Attaining correct
alignment, rotation, and length without disrupting the soft-tissue attachments to the comminuted
fragments often leads to successful healing.
Fortunately, even in the elderly, the cortical bone of the medial and lateral columns usually
provides good purchase for bone screws. In a biomechanical study of internal fixation of the distal
humerus, Helfet and Hotchkiss (5) found that double-plate construction with the two plates at right
angles, a medial plate on the medial column and a posterior plate on the lateral column, provided the
strongest fixation regardless of whether the plate was a one-third tubular or a 3.5 mm reconstruction
plate. Schemitsch et al. (4) looked at plates of two designs placed in five different configurations. They
found that when cortical contact was present, dual plates placed medially and laterally whether at
90° to each other or in the same plane provided equivalent rigidity. When a cortical gap was
present, however, they found that the combination of an anatomically designed lateral buttress Jplate and a medial reconstruction plate gave the greatest rigidity. Reestablishment of good bone
contact throughout the construct, using tricortical bone graft from the iliac crest if necessary,
substantially improves fixation and chances for union.
In our study patients in whom two reconstruction plates were used, obtained the best result
with a mean Mayo score of 89.17. Mean Mayo score was marginally higher in distal multiple hole
plate group with a value of 90.83, but its use was limited as it could not be used in patients having
more distally situated metaphyseal fracture. With the use of two reconstruction plates Mayo score
was initially low with a mean of 77.50 at two months, due to impingement of soft tissue but it
significantly improved with physiotherapy. Two reconstruction plate construct was the most stable
as compared to other plating methods and failure of fixation was zero percent in this study.
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While functional bracing has been shown to result in good outcomes in some case, some
surgeons continue to favor operative fixation (6). Management is determined by fracture pattern
and degree of comminution (7). Radial nerve injury, difficulty in controlling fracture alignment and
elbow stiffness are some of the concerns with functional bracing (8). Jawa et al. compared
functional bracing and plate fixation for treatment of extra-articular distal-third diaphyseal
humeral fractures and found that operative treatment achieves more predictable alignment and
potentially quicker return of function but risks iatrogenic nerve injury and infection and the need
for reoperation. According to him functional bracing can be associated with skin problems and
varying degrees of angular deformity, but function and range of motion are usually excellent (9).
Tejwani et al. compared rigidity of fixation provided by one locking plate versus two
reconstruction plates in a laboratory study on eight pairs of matched humerus fracture and
concluded that double-plating provides a more rigid fixation than a single-locked plate for fixation of
extra-articular comminuted distal humeral fractures (10).
In an experimental in vitro study, Korner et al. concluded that the biomechanical behavior of
the osteosynthesis depends more on plate configuration than plate type. Advantages of locking
compression plates are only significant if compared with dorsal plate application techniques (11).
Qing Yang et al. found that an oblique MLCP applied via a posterior approach achieved an adequate
internal fixation and obtained an excellent functional outcome. In our study there was no failure with
Oblique Metaphyseal Locking Compression Plate but medial pillar was less stable and Mayo score
was comparatively low (12).
The goal of operative treatment of humeral shaft fractures is to reestablish length, alignment,
and rotation with stable fixation that allows early motion and ideally early weight bearing on the
fractured extremity. If the goal of stable fixation that allows early motion is met, rehabilitation can
begin within 3 days of surgery. Waddell et al. showed that disabling stiffness develops if the elbow is
immobilized for more than 3 weeks. Supervised physical therapy sessions are scheduled three times
a week, along with a daily home exercise program. Dynamic flexion and extension splinting is
prescribed when early motion goals are not obtained. (13)
CONCLUSION: Following surgical treatment of adult extra-articular distal humeral fractures, double
plating with reconstruction plates provide a more rigid fixation than a single-locked plate. The higher
stability achieved permits early mobilization. Exploration of nerves is a pre-requisite to avoid nerve
injury. Initial impingement improves with physiotherapy and this obtains higher percentage of
excellent results.
REFERENCES:
1. Sim FH, Morrey BF. Non-union and delayed union of distal humeral fractures. In: Morrey BF,
ed. The elbow and its disorders. Second ed. Philadelphia: W.B. Saunders Co., 1993:367-82.
2. Sanchez-Sotelo J, Torchia ME, O’Driscoll SW: Principle-based internal fixation of distal
humerus fractures, Tech Hand Upper Extremity Surg 5:179,2001
3. Self J, Viegas SF, Buford WL, et al: A comparison of double-plate fixation methods for complex
distal humerus fractures. J Shoulder Elbow Surg 4:51, 1995.
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4. Schemitsch EH, Tencer AF, Henley MB. Biomechanical Evaluation of Methods of Internal
Fixation of the Distal Humerus. J Orthop Trauma 1994; 8:468.
5. Helfet DL, Hotchkiss RN. Internal Fixation of the Distal Humerus: A Biomechanical
Comparison of Methods. J Orthop Trauma 1990; 4:260.
6. Sarmiento A, Horowitch A, et al. Functional bracing for comminuted extra-articular fractures
of the distal third of the humerus. J Bone Joint Surg Br. 1990 Mar; 72(2):283-7.
7. Ali A, Douglas H, et al. Revision surgery for nonunion after early failure of fixation of
fractures of the distal humerus. J Bone Joint Surg Br. 2005 Aug; 87(8):1107-10.
8. McKee MD. Fractures of the shaft of the humerus. In Rockwood and Green’s Fractures in
Adults. Bucholz RW, Heckman JD, Court-Brown CM, Editors. 2006, Lippincott Williams &
Wilkins: Philadelphia. p. 1117-1159.
9. Jawa A, McCarty P, et al Extra-articular distal-third diaphyseal fractures of the humerus. A
comparison of functional bracing and plate fixation. J Bone Joint Surg Am. 2006
Nov;88(11):2343-7.
10. Tejwani NC, Murthy A, et al. Fixation of extra-articular distal humerus fractures using one
locking plate versus two reconstruction plates: a laboratory study. J Trauma. 2009 Mar;
66(3):795-9.
11. Korner J, Diederichs G, et al. A biomechanical evaluation of methods of distal humerus
fracture fixation using locking compression plates versus conventional reconstruction
plates. J Orthop Trauma. 2004 May-Jun; 18(5):286-93.
12. Quing Yang, Fang Wang, et al. Surgical treatment of adult extra-articular distal humeral
diaphyseal fractures using an oblique metaphyseal locking compression plate via a posterior
approach. Med Princ Pract 2012; 21:40-45.
13. Waddell JP, Hatch J, Richards R: Supracondylar fractures of the humerus-results of surgical
treatment, J Trauma 28:1615, 1988
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